Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Chestnut Ridge Nsg & Rehab Ctr during CMS and state inspections, most recent first.
Medication Administration Errors Exceeded Facility Threshold: An LPN failed to administer some ordered medications because they were unavailable and did not notify the physician of the missed doses. During the same medication pass, the LPN gave Isosorbide Mononitrate ER incorrectly, administered Clonidine outside the ordered BP parameters, and gave the wrong total dose of Allopurinol. In a separate observation, Pantoprazole delayed-release tablets were crushed for a resident with GERD. The facility policy required medications to be administered safely and as prescribed, and the DON stated the expected medication error rate was below 5%.
An LPN failed to disinfect an insulin vial top before drawing insulin and used the same BP cuff for two residents on EBP without disinfecting it between uses. Housekeeping staff poured liquid from resident cups into a mop bucket, and nursing staff exited resident rooms wearing gloves and handled items without hand hygiene. In addition, communal shower rooms contained multiple unlabeled and mixed personal items belonging to residents.
Unclean communal showers and dining room: The facility failed to keep the dining room and 2 communal shower rooms clean, safe, and homelike. Observations found cluttered and unsanitary shower areas with mixed personal items, debris, residue, used linens, and dirty items on the floor, as well as a sticky dining room with used silverware, trash, and food on the floor and tables. Staff stated CNAs were supposed to clean showers after each use, and an RN consultant confirmed the lack of cleanliness.
A resident with moderate cognitive impairment and a history of CVA was observed wearing broken glasses after a CNA placed a meal tray on them and broke them. Nursing and SSA notes documented the incident, and the resident reported she had not been told whether the glasses would be repaired or replaced. The DON confirmed the glasses were broken by staff and that the facility would absorb the replacement cost.
Failure to provide written bed hold and transfer notices for two residents. One resident with colon cancer, anemia, ileostomy, diverticulitis, and psychiatric diagnoses was transferred to the hospital, and another resident with COPD and weakness was discharged, but neither record showed a written notice explaining the transfer/discharge or the bed hold policy. The BOM confirmed no bed hold notice was found, an LPN said residents should receive the policy, and the Ombudsman reported no notification for either resident.
Inaccurate MDS coding for elopement risk was identified for two residents. Both had severe cognitive impairment on BIMS, care plans that identified wandering or exit-seeking behavior and wander guard use, and observations confirmed wander guard bracelets in place, yet Section P of the quarterly MDS assessments coded alarms as not used and the physician's orders did not include orders for the wander guards. MDS Coordinators confirmed the coding errors.
Oxygen was not administered per physician orders for two residents. One resident with significant cardiopulmonary history had no oxygen order in the EMR when staff observed oxygen running at 2.5 LPM, and another resident with respiratory failure, CHF, and ESRD had an order for 2 LPM via NC but was observed at 1 LPM because the resident preferred it that way; an LPN stated staff kept it at 1 LPM despite the order.
Controlled substance records were not maintained accurately for a resident receiving Methadone for chronic pain. RN HH documented the dose in the MAR but did not enter it in the controlled substance log, and surveyors found the controlled substance book had torn, loose, and unsecured pages. The DON stated nurses must document controlled substances immediately after administration and ensure there are no missing signatures or loose pages.
Therapeutic diets were not consistently provided as ordered for two residents. One resident with CHF, DM2, dysphagia, CKD, and a history of aspiration was observed receiving pureed foods and other items that did not match the meal ticket or the documented mechanical soft diet plan. Another resident with CHF, DM2, anemia, CKD, and dementia was served shredded meat and a side item that did not match the meal ticket or the ordered mechanical soft, reduced concentrated sweets, no added salt diet. The DM and DON confirmed the tray contents did not match the active orders.
A resident with severe cognitive impairment was stabbed by another resident in a shared room after the other resident gained access to the bathroom area. Staff found the resident with a bleeding laceration, applied pressure, and called 911 while police responded and later found the knife in the toilet. The injured resident was sent to the hospital, and interviews confirmed the incident involved resident-to-resident physical abuse.
An LPN handed medication to another LPN for administration without the second nurse verifying the order, and another resident’s MAR showed meds documented as given even though they were not available or administered. The facility also had delays in PRN pain medication refills, missed ordered weights for a resident with malnutrition and failure to thrive, blood sugars checked only at bedtime instead of before meals and at bedtime, and a wound vac found disconnected and left on a bedside table.
Accident Hazards and Supervision: The facility failed to keep resident areas free of accident hazards and did not provide adequate supervision for two residents. One resident with severe cognitive impairment and a history of falls had an unsecured shaving razor left on the windowsill in his room, while another resident with a BKA, diabetes, and a transfer restriction sustained a thigh blister after being served very hot coffee in a thin plastic cup and carrying it in his wheelchair.
The facility failed to conduct annual competency evaluations for CNAs, as required by their policy. Despite meeting state in-service training requirements, the facility could not provide documentation of yearly evaluations for sampled CNAs. The Director of Human Resources confirmed that no evaluations had been completed in four years, with the responsibility lying with the DON, a position with high turnover.
The facility failed to meet food safety standards, with improperly labeled and stored food items, and cold fruit served at an incorrect temperature. An ice machine was also found to be unsanitary. These issues were confirmed by staff during a survey.
The facility failed to maintain the area around the dumpster free from garbage and refuse, contrary to its policy. Observations revealed garbage on the ground, and a staff member admitted to leaving the dumpster lid open when it was too full, allowing wind to scatter garbage. This practice had the potential to attract pests.
The facility failed to maintain a safe and homelike environment, with observations of dirty PTAC filters, walls in disrepair, and missing ceiling tiles in resident rooms and the kitchen. The maintenance policy required regular cleaning and upkeep, but observations showed non-compliance, confirmed by the Corporate Maintenance Director. These deficiencies posed potential risks to residents' safety and quality of life.
A facility failed to conduct a PASARR Level II assessment for a resident admitted with PTSD, depression, and anxiety. The PASRR Level I form did not include these diagnoses, and no Level II assessment was completed. Staff interviews revealed uncertainty about responsibility for ensuring accurate diagnoses on the PASRR form.
The facility failed to implement comprehensive care plans for four residents, leading to unmet medical and personal care needs. One resident's refusal of medications was not documented in the care plan, while another's personal hygiene requests were ignored. Two other residents experienced inadequate personal care, with observations of poor hygiene and lack of assistance, despite documented ADL deficits.
The facility failed to provide adequate assistance with ADLs for three residents, leading to unmet needs in personal hygiene and grooming. A resident with multiple diagnoses did not receive scheduled showers, resulting in oily hair and dirty fingernails. Another resident required assistance with nail care, which was not provided, and a third resident requested help with facial hair removal, which was ignored. Staff interviews confirmed that these services should have been provided but were not.
The facility failed to ensure soiled linen hampers in hallways were emptied immediately when full, as required by policy. Observations showed overflowing hampers on the A and C halls, with lids left ajar, indicating they were not being emptied promptly. Interviews confirmed CNAs were responsible for emptying hampers every two hours and during mealtimes, but accountability was inconsistent despite in-service training sessions.
Medication Administration Errors Exceeded Facility Threshold
Penalty
Summary
Medication administration errors occurred during observations and record review, resulting in a medication error rate of 24% based on 6 of 25 medication opportunities. The facility policy titled Administering Medications stated that medications shall be administered in a safe and timely manner, and as prescribed. During an observation on A-Hall, an LPN failed to administer Glipizide 10 mg twice daily and Fluticasone-Salmeterol inhalation powder 500/50 mcg twice daily for a resident with DM and COPD because the medications were not available, and the physician was not notified of the missed doses. During the same observation, the LPN administered Isosorbide Mononitrate ER 120 mg incorrectly by giving one 60 mg tablet instead of two tablets to equal 120 mg, despite a written note on the medication card stating to give 2 tablets to equal 120 mg. The LPN also gave Clonidine HCL 0.1 mg when the resident's blood pressure was 150/59, which was outside the ordered parameters of systolic blood pressure greater than 160 or diastolic greater than 100. In addition, Allopurinol was administered as three 100 mg tablets for a total of 300 mg when the physician's order was for Allopurinol 300 mg, give 2 tablets by mouth in the morning for gout flare. In a separate observation, Pantoprazole Sodium delayed-release 40 mg for a resident with GERD was crushed even though it should not have been crushed.
Infection Control Lapses During Medication Pass, Housekeeping, and Communal Shower Use
Penalty
Summary
Infection prevention and control practices were not followed during medication administration and resident care activities. During insulin administration for a resident with diabetes mellitus, an LPN drew Lantus insulin without disinfecting the top of the insulin vial. During another medication pass, the same LPN used the same blood pressure cuff for two residents who were both on Enhanced Barrier Precautions without cleaning or disinfecting the cuff between uses. The LPN stated she forgot to wipe down the cuff and did not have disinfectant wipes in her medication cart at the time. Housekeeping and nursing staff also failed to follow infection control practices while moving through resident care areas. A Housekeeping Aide emptied liquid from resident cups into the mop bucket used to clean resident rooms on the hall. A CNA exited a resident room wearing one glove while carrying soiled linen down the hallway, and an RN exited a resident room wearing one glove, removed it, and then opened the medication cart and handled items without performing hand hygiene. The RN confirmed he did not perform hand hygiene after glove removal and acknowledged walking through the hallway wearing one glove and touching items in the medication cart without hand hygiene. Multiple communal shower room observations showed personal care items and resident belongings mixed together and not labeled. In the women's shower room, unlabeled shampoo and skin cleanser bottles, an open bottle of shampoo, a reusable water bottle, resident clothing, a cell phone, clean towels and washcloths, a dirty gown, and other personal items were observed in the stalls and on shelves, benches, and a wheelchair. In the men's shower room, a partially used shampoo bottle, an electric razor, shampoo and conditioner, and open bottles of lotion were observed together, and the shower stretcher had a greenish colored liquid pooling in the center. Staff interviews confirmed the personal care items were mixed in the communal bathrooms and were not labeled.
Unclean communal showers and dining room
Penalty
Summary
The facility failed to maintain the dining room and 2 of 2 communal shower rooms in a safe, clean, comfortable, and homelike environment. Review of the Housekeeping Operations Manual stated that a main area of concern in a healthcare facility is the transmission of bacteria. During observation of the women's communal bathroom, numerous bottles of shampoo, lotion, grooming items, hairbrushes, scissors, wipes, lotions, and cleaning products were scattered and intermixed on a shelf without labels. Small pieces of debris were on the shower room floor, residue was noted along the lower tile wall, used washcloths were on the hand grab bar, a resident gown was draped over a wheelchair holding both clean and used linen, and a dirty slipper sock was on the floor in front of the toilet. The foam pad on the shower stretcher had small openings with debris accumulation. The men's communal shower also contained clutter, including thera-gel shampoo, a resident hat, a used electric shaver, baby lotion, open containers of wipes, and briefs. Observation of the dining room revealed used silverware, trash, and a cookie on the floor, along with trash on the dining area tables. The dining tables and floor were sticky and did not appear to have been recently wiped or mopped. A CNA stated that nursing assistants are supposed to clean the shower rooms after each resident use. The HKD stated the multi-use showers are cleaned at 8:00 AM, 12:00 PM, and 3:00 PM, and that CNAs are supposed to clean them following each use and remove towels after use. The Regional Nurse Consultant confirmed the lack of cleanliness during the tour of the men's and women's bathrooms. A CNA also stated that the shower chair and bath stretcher should be sanitized between uses and that she had not been trained to sanitize the equipment.
Broken Resident Glasses Not Protected
Penalty
Summary
The facility failed to promote dignity by not exercising reasonable care and protection to prevent damage to a resident’s glasses. R109 was observed in bed wearing broken glasses, including one arm broken off, and stated that a staff person broke the glasses when something was placed on top of them. R109 said she had informed the nurse when it happened a couple of weeks earlier and had not been told whether the glasses would be repaired or replaced. On a later observation, R109 was still in bed wearing glasses that were seated crooked on her face, and she again stated that no one had given her any information about replacement or repair. Record review showed R109 had a physician order for ophthalmic care as needed, a BIMS score of 10 indicating moderate cognitive impairment, and diagnoses including CVA and hypertension. Her care plan addressed reading material but did not specify that she required glasses for reading. Nursing documentation stated that a CNA broke the glasses when a meal tray was placed on top of them, and social services documented that the resident’s responsible party requested vision services for a new pair of glasses. The DON confirmed the CNA placed the meal tray on the glasses and broke them, and also confirmed the facility would absorb the cost of replacement.
Failure to Provide Written Bed Hold and Transfer Notices
Penalty
Summary
The facility failed to ensure that two sampled residents, R131 and R133, were provided with a written bed hold notice or the reason for transfer at the time of transfer or discharge. The facility policy titled Transfer or Discharge Notice stated that residents and/or their representatives are to be notified in writing of the reason for transfer or discharge, the effective date, the location of transfer or discharge, appeal rights, the facility bed hold policy, and the Ombudsman contact information, and that a copy is to be sent to the Office of the State Long-Term Care Ombudsman. R131’s record showed diagnoses including malignant neoplasm of the colon, anemia, ileostomy, diverticulitis, schizoaffective disorder, bipolar type, and schizophrenia, and an MDS assessment with a BIMS score of 15 indicating little to no cognitive impairment. The clinical census showed R131 was transferred to the hospital from the oncologist office and later from the facility to the hospital, with the bed hold expiring and billing stopped before readmission, but the record contained no evidence that a bed hold notice or reason for transfer was provided. R133’s record showed diagnoses including COPD and weakness, and the clinical census showed discharge, but there was no evidence of a bed hold notice, review of the bed hold policy, or reason for transfer in the record. The BOM confirmed there was no bed hold notice located and no documentation of contact with R133 about the bed hold policy, and an LPN stated residents are supposed to go with a bed hold policy, but could not find a copy for either resident. The Ombudsman office also reported no notification of discharge or transfer for either resident.
Inaccurate MDS Coding for Elopement Risk
Penalty
Summary
The facility failed to ensure that MDS assessments were accurate for two residents who were identified as being at risk for elopement. Review of the policy titled Wandering, Unsafe Resident stated residents are to be assessed for elopement and unsafe wandering risk upon admission and throughout their stay, with the interdisciplinary team evaluating contributing factors and communicating changes in interventions. For one resident, the EMR showed diagnoses including vascular dementia, mild, with mood disturbance, psychotic disturbance and mood disturbance, and anxiety. The quarterly MDS documented a BIMS score of 03 indicating severe cognitive impairment and coded alarms as not used in Section P. The care plan documented that the resident was at risk for elopement, exhibited exit-seeking behavior, and had a wander guard, but the physician's orders contained no order for the wander guard. The facility's Wander Guard List included the resident, and observation confirmed a wander guard bracelet applied around the ankle. For the second resident, the EMR showed diagnoses including unspecified dementia, unspecified mood, major depressive disorder, anxiety disorder, and other symptoms and signs involving appearance and behavior. The quarterly MDS also documented a BIMS score of 03 and coded alarms as not used in Section P. The care plan identified the resident as a wanderer who sometimes went into other residents' rooms related to disoriented place, with interventions including wander guard placement, yet the physician's orders again contained no order for the wander guard. The Wander Guard List included this resident, and observation confirmed a wander guard bracelet applied around the ankle. MDS Coordinators confirmed that both quarterly MDS assessments were inaccurately coded in Section P.
Oxygen Not Administered Per Physician Orders
Penalty
Summary
The facility failed to ensure oxygen was administered according to physician orders for two residents who used oxygen. One resident had diagnoses including acute respiratory failure with hypoxia, sleep apnea, chronic systolic CHF, paroxysmal atrial fibrillation, atherosclerotic heart disease, prior CABG, and anemia. The resident’s care plan addressed altered respiratory status and included oxygen administration as indicated, but the physician orders section had no oxygen order until 03/03/2026, when an order was added for oxygen at 2 LPM via nasal cannula continuously. Despite this, observations on 03/02/2026 and 03/03/2026 showed the resident wearing oxygen via nasal cannula while the concentrator was set at 2.5 LPM. For the second resident, diagnoses included acute respiratory failure with hypercapnia, sleep apnea, morbid obesity, acute on chronic systolic CHF, cardiac arrhythmia, hypertension, and ESRD. The resident’s MDS indicated little to no cognitive impairment and use of oxygen. The care plan directed staff to monitor respirations and pulse oximetry, position the resident to promote breathing, and administer oxygen therapy per physician orders. The physician order dated 11/04/2024 specified oxygen at 2 LPM via nasal cannula to keep SpO2 above 92%. During observation, the resident was seated in a wheelchair with a nasal cannula connected to a portable oxygen tank set at 1 LPM. The resident stated she told the nurse to keep the oxygen at 1 liter and acknowledged the order was for 2 liters, but preferred it at 1 liter. On the following day, the tank was again observed set at 1 LPM, and the LPN stated staff maintained oxygen at that level per the resident’s request even though the physician order remained for 2 liters. The LPN also stated the oxygen had been kept at 1 liter for a long time and was unsure whether the prescribing physician had been notified.
Controlled Substance Documentation Not Maintained
Penalty
Summary
The facility failed to maintain accurate records on controlled substances for a resident receiving Methadone HCl 10 mg tablets ordered as 2 tablets by mouth every 8 hours as needed for chronic pain. Review of the electronic medical record showed the resident received Methadone on 03/04/2026 at 10:47 AM, but review of the controlled substance record book for that administration showed no documentation by the administering nurse at the time the medication was given, contrary to the facility policy requiring medications to be administered in a safe and timely manner and as prescribed. During observation of the nurse's medication cart with RN HH, surveyors found the controlled substance record book had multiple pages that were torn, loose, and no longer secured within the binder, and the pages easily fell out during inspection. RN HH stated she documented the administration in the MAR at 10:47 AM but did not make an entry in the controlled substance log, and she acknowledged missing pages had been discovered in the book. The DON stated nurses are required to document controlled substances immediately after administration in the controlled substance log and ensure there are no missing signatures or loose pages.
Therapeutic diets were not consistently matched to physician orders
Penalty
Summary
Therapeutic diets were not consistently provided as ordered for two residents, R90 and R34. R90 had diagnoses including CHF, DM2, dysphagia, CKD, and a history of pneumonitis/aspiration. The record showed a diet order upgrading R90 from pureed to mechanical soft texture with regular consistency, while the care plan and annual nutritional assessment still referenced pureed meat or pureed meat/mechanical soft consistency with some items allowed as tolerated. During lunch observations, R90 was served pureed meat and pureed side items, and on another occasion was served pureed roast beef and other pureed foods; the meal tickets indicated mechanical soft sides and, at times, different combinations of pureed and mechanical soft items. The DM verified that the meal served did not match the meal ticket. R34 had diagnoses including CHF, DM2, anemia, CKD, and dementia, and had an order for a reduced concentrated sweets, no added salt diet with mechanical soft texture and regular consistency. The annual diet assessment also specified reduced concentrated sweets, no added salt, mechanical soft diet, but the care plan did not document specific dietary instructions or interventions. During lunch observation, R34 was not eating and was served shredded roast beef with gravy, mashed potatoes, and squash; the meat was in strands with pieces large enough to require chewing and did not appear mechanically altered. R34 was also served pineapple chunks instead of cinnamon applesauce as listed on the meal ticket, and the meal ticket specified ground roast beef. The DM and DON confirmed the meal served did not match the ticket and that the tray slips and active orders were inconsistent.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to ensure one resident was free from physical abuse when another resident entered the room and stabbed him with a knife. The injured resident had severe cognitive impairment with a BIMS score of 04 and required assistance with self-care and mobility, including use of a wheelchair. During the incident, staff observed the resident with a bleeding laceration, applied gauze and pressure to control the bleeding, and called 911 while law enforcement was contacted. The resident was then transported to the hospital. Staff interviews described that the other resident came out of a shared bathroom after the stabbing, and police later found the knife in the toilet. The administrator stated the resident who committed the act was handcuffed and taken by police, and that the injured resident’s daughter was notified and later updated. The report also noted that the injured resident had behavioral outbursts, while the other resident was described as typically pleasant and independent.
Failure to Follow Orders for Medications, Monitoring, Weights, Pain Control, and Wound Vac Care
Penalty
Summary
The facility failed to provide care and treatment in accordance with physician orders and its own policies for multiple residents. During observation, an LPN handed a cup of pills to another LPN in the hallway and asked her to administer the medication to a resident, even though the second nurse was not the nurse who pulled the medication and did not verify the medication order before giving it. The first nurse stated she only hands medications to another nurse in emergency situations, and the second nurse confirmed she administered the medication without knowing what was in the cup. For one resident with diabetes and COPD, the MAR showed Glipizide and Fluticasone-Salmeterol documented as administered at the scheduled medication pass, but the medications were not available in the facility and were not actually given. The nurse who documented the medications confirmed she recorded them as given even though they were not administered. For another resident with chronic pain and neuropathy, the record showed a PRN Tramadol order expired and there was a six-week gap before a new order was placed. The resident and daughter reported repeated delays in pain medication refills and that PRN pain medication was sometimes not given when requested, while staff confirmed the PRN Tramadol was not in the cart and they did not know when it had run out. The facility also failed to follow ordered monitoring and treatment for other residents. One resident with severe cognitive impairment, malnutrition, and failure to thrive had ordered weekly weights, but several weights were missed and there was no documented weight for more than a week before the resident later presented to the emergency department with a much lower weight than the last recorded facility weight. Another resident with vascular dementia and diabetes had orders for blood sugar checks before meals and at bedtime, but the record showed checks were done only once daily at bedtime. For a resident admitted with acute osteomyelitis and a wound vac, the wound vac was observed disconnected and sitting on the bedside table, and the resident stated staff had taken it off; the device remained not connected during later observation, and the record showed conflicting suction settings documented for the wound vac.
Accident Hazards and Supervision
Penalty
Summary
The facility failed to ensure the environment remained as free of accident hazards as possible and failed to provide adequate supervision for two residents, R145 and R49. The facility policy stated that residents should be provided an environment free of accident hazards and that adequacy of supervision is based on the individual's assessed needs and identified hazards in the resident's environment. R145 was admitted with diagnoses including Alzheimer's disease, unspecified dementia, aphasia, depression, COPD, anemia, GERD, hyperlipidemia, chronic cough, overweight, skin and subcutaneous tissue disorders, and a history of falling. His MDS showed a BIMS score of 00, indicating severe cognitive impairment, and his care plan addressed cognitive impairment and a history of falling with prior fractures, with interventions including monitoring, appropriate supervision, and safety measures. Despite this, observation found a shaving razor unsecured on the windowsill in R145's room, and it remained there on a later observation, even after being placed inside a clear plastic bag. R49 had diagnoses including type 2 diabetes mellitus, acquired absence of the right leg below the knee, polyneuropathy, and dysphagia. His MDS showed a BIMS score of 15, and a physician order stated he could not walk or transfer with his prosthetic on, required a sliding board for wheelchair-to-bed transfers, and was not to go to the bathroom. His care plan included anticipating and meeting needs, keeping the call light within reach, and responding promptly to requests for assistance. Review of records showed a blister on the left upper lateral thigh that was documented after the resident stated he had been carrying a cup of coffee in his wheelchair between his left thigh and the arm of the wheelchair when the burn occurred. The resident later stated he had been given very hot coffee in a thin plastic cup that was not appropriate for hot liquids.
Failure to Conduct Annual CNA Competency Evaluations
Penalty
Summary
The facility failed to conduct annual performance reviews to ensure competency for the Certified Nursing Assistants (CNAs) employed by the facility, as required by their policy titled Competency of Nursing Staff. The policy mandates that competency evaluations be conducted upon hire, annually, and as deemed necessary. However, the facility was unable to provide documentation of yearly competency evaluations for the sampled CNAs, despite meeting the state in-service training requirements. Specifically, CNA MM, who was hired in 2004, only had an evaluation from 2005, and there were no evaluations for CNA LL and CNA NN, hired in 2018 and 2017, respectively. Interviews revealed that the Director of Human Resources and Payroll, who has been with the facility for four years, confirmed that no competency evaluations had been completed for any CNAs during her tenure. The responsibility for these evaluations lies with the Director of Nursing (DON), a position that has experienced high turnover rates, making it difficult to maintain consistent oversight. The current DON is new to the position, and the facility acknowledged the need to address the completion of competency evaluations for the nursing staff.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several observations during a survey. In the kitchen, an open bag of breaded chicken patties and an open box of sweet potato pie were found in the walk-in freezer without open or discard dates and were left open to air. Additionally, a container of peaches and a metal container of coleslaw in the walk-in cooler were improperly dated, and various cheeses and seasonings were not labeled with open or discard dates. These lapses were confirmed by a staff member, who admitted to not labeling the items due to time constraints. Further deficiencies were noted during meal preparation, where cold fruit was served at an inappropriate temperature of 68 degrees Fahrenheit. The Regional Dietary Manager acknowledged that this was not the correct serving temperature. Additionally, an ice machine in the kitchen was found to have discoloration on the inside, indicating a lack of cleanliness. The responsibility for cleaning the ice machine was attributed to the Maintenance department, as confirmed by a staff member.
Improper Garbage Disposal Around Dumpster
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse around the dumpster area, as observed during a survey. The facility's policy, revised in October 2017, mandates that garbage and refuse containing food wastes be stored in a manner inaccessible to pests, with outside dumpsters kept closed and free of surrounding litter. However, during an initial tour of the kitchen, it was observed that garbage and refuse were present on the ground around the dumpster. An interview with a staff member revealed that when the dumpster became too full, the lid was left open to make more room for garbage, which allowed the wind to blow garbage out onto the ground. This practice was contrary to the facility's policy and had the potential to attract pests.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by observations of dirty filters in the Packaged Terminal Air Conditioner (PTAC) units, walls in disrepair, missing paint, missing chair rails, and missing or falling ceiling tiles in nine resident rooms across three halls and the kitchen. The facility's maintenance policy required regular upkeep of the building and equipment, including cleaning PTAC filters every three months. However, observations revealed that the PTAC filters in multiple rooms were covered in a gray, fuzzy substance, indicating they had not been cleaned as per the recommended schedule. Additionally, walls in several rooms had peeling wallpaper, missing chair rails, and mismatched paint, further contributing to the deficient environment. Interviews with the Corporate Maintenance Director and the Administrator in Absence confirmed the observations and acknowledged that the PTAC filters should be cleaned monthly and documented in the TELS system. The maintenance director also stated that the building should be maintained in good repair, with issues such as peeling wallpaper and missing chair rails addressed promptly. The report highlights that these deficiencies had the potential to place residents at risk for accidents and hazards, diminishing their quality of life.
Failure to Conduct PASARR Level II Assessment for Resident with Mental Disorder
Penalty
Summary
The facility failed to ensure that a resident with a serious mental disorder was referred for a Level II PASARR assessment upon admission or within 30 days of a new diagnosis. The resident, identified as R99, was admitted with diagnoses including PTSD, depression, and anxiety. However, the PASRR Level I request dated 12/20/2022 did not include these diagnoses, and there was no subsequent PASARR Level II assessment conducted. This oversight was identified through staff interviews, record reviews, and a review of the facility's policy on coordinating assessments with the PASARR program. Interviews with the Social Services Director and the Director of Nursing revealed uncertainty about who was responsible for ensuring the accuracy of diagnoses on the PASRR Level I form upon admission. The Director of Nursing confirmed that the PASRR Level I form for R99 did not reflect the resident's actual diagnoses, and no PASRR Level II assessment was completed. This deficiency had the potential to affect the appropriate level of care and services provided to the resident.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for four residents, leading to potential risks for medical complications and unmet needs. For one resident, R84, the care plan did not address the resident's behavior of refusing medications, such as docusate sodium and acetaminophen, despite documentation in nurse's progress notes indicating multiple refusals. Interviews with staff, including the LPN/UM and MDS LPNs, confirmed that such behaviors should be documented and included in the care plan, but this was not done. Another resident, R50, was observed with facial hair and reported that staff had not assisted her with personal hygiene despite her requests. The care plan for R50 noted ADL and cognitive deficits but lacked specific interventions for personal hygiene. Interviews with the LPN/UM and DON revealed that personal hygiene needs should be addressed in the care plan and added to the task list, but this was not implemented. Residents R20 and R90 also experienced deficiencies in personal care. R20 was observed with oily hair and dirty fingernails, and reported not receiving a bath since admission, despite the care plan indicating a self-care deficit and need for assistance with ADLs. Similarly, R90, who required maximum assistance for ADLs, was observed with long, dirty fingernails and expressed a desire for assistance in cutting them. The care plan for R90 did not adequately address these personal hygiene needs, leading to unmet care requirements.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for three residents, leading to unmet needs in personal hygiene and grooming. Resident R20, who was admitted with multiple diagnoses including skin infection and diabetes, required substantial assistance with bathing and moderate assistance with personal hygiene. Despite being scheduled for showers twice a week, R20 reported not receiving a bath since admission, and observations confirmed her hair was oily and her fingernails were dirty. Interviews with staff revealed that nail care should accompany showers, but R20's needs were not met, as staff were reportedly too busy or unhelpful. Resident R90, with diagnoses including peripheral vascular disease and dementia, required substantial assistance for personal hygiene. Observations showed R90's fingernails were long and dirty, and he expressed a desire for assistance with nail care. Staff interviews indicated that nail care should occur on shower days, but this was not provided. Resident R50, with moderate cognitive impairment, required assistance with personal hygiene and had requested help with facial hair removal, which was not provided. Observations confirmed the presence of facial hair, and staff interviews indicated that CNAs should ask residents if they want facial hair removed, but this was not done for R50.
Failure to Empty Soiled Linen Hampers Promptly
Penalty
Summary
The facility failed to ensure that soiled linen hampers located in the hallways were emptied immediately when full, as required by their policy. Observations revealed that on multiple occasions, soiled linen hampers on the A and C halls were overflowing, with lids left ajar, indicating they were not being emptied promptly. This was observed during a facility tour and subsequent visits, where hampers were found overflowing in the hallways, including in front of a resident's room without any CNA present to address the issue. Interviews with facility staff, including the Housekeeping Director and CNAs, confirmed that the responsibility for emptying the soiled linen hampers fell on the CNAs, who were expected to do so at least every two hours and during mealtimes. However, the Regional Nurse Consultant acknowledged that ensuring hampers were emptied when full had been a persistent issue. Despite in-service training sessions conducted to address this, staff interviews indicated a lack of consistent accountability among CNAs for maintaining the cleanliness of the hampers.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 148 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cumming
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cumming Operating Company Llc | 0.9 mi | ★★★★★ | 5 | 0 |
| Pruitthealth - Lanier | 9.7 mi | ★★★★★ | 0 | 0 |
| D Scott Hudgens Center For Skilled Nursing, The | 12.7 mi | ★★★★★ | 2 | 0 |
| Salude - The Art Of Recovery | 13.2 mi | ★★★★★ | 0 | 0 |
| Crossroads Of Flowery Branch Of Journey Llc, The | 13.5 mi | ★★★★★ | 15 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.